Ashfield Court

Ashfield Court is a 'care home'. Ashfield Court provides personal care and accommodation to up to 46 older people, some of whom live with dementia, across two floors in one purpose-built home.

We found the following examples of good practice:

• Staffing levels were safe. Staff worked on separate floors and did not mix to ensure risks were minimised; entrances and changing areas had been rearranged to accommodate this.

• All visitors had to undergo a temperature check and answer a range of relevant questions. There was ample PPE and handwashing facilities available, along with clear signage prior to entry.

• The premises had been adapted where practicable to enable better social distancing for people and staff. For instance, seating had been reduced in the dining room and screens introduced.

• The registered manager worked well with external stakeholders such as commissioners and specialist health teams. Senior leaders had provided additional support during the outbreak.

Further information is in the detailed findings below.

People’s experience of using this service and what we found

The new manager had made a range of improvements to record keeping and staffing to ensure people’s needs were safely and effectively met.

Risk assessments contained improved person-centred information. Daily recording information was accurate and up to date. People were kept safe through good staff knowledge and awareness.

The manager worked proactively in consultation with external healthcare professionals.

Feedback from people, their relatives and a range of external professionals was positive regarding the compassionate, affectionate and sensitive approach of staff. The service felt welcoming and calm as a result.

People were included in the running of the service. The manager had planned formal resident and relative meetings and was accessible and approachable.

People ate well and had a choice of meals and snacks. Menus were varied and staff were patient when helping people decide what meals to choose.

The premises were suitable and spacious. People’s rooms were clean and well decorated. The first floor was specifically for people living with dementia and areas could be improved with better regard to best practice about dementia friendly environments. We have made a recommendation about this.

The manager planned improvements in end of life care training. Currently, there was sufficient information gathered through discussion with people and their families about how they wanted to be supported at this time.

Activities were in place and there had been some recent improvements to community involvement. Feedback from people and relatives was consistent in that they felt there should be more outings. The manager had acknowledged this and was planning appropriately. We have made a recommendation about this.

The manager was well respected in the organisation and further afield. They were open and supportive with staff and liaised well with external professionals.

Training compliance had improved significantly under the new manager and further additional training was planned.

Clear systems were in place for the review and audit of all aspects of the service. Where auditing could be improved to focus more on quality, the manager took on board this advice.

Medicines were managed safely, in line with best practice. Covert medicines and medicines to be given ‘when required’ were well supported by clear paperwork. The premises were well maintained and appropriate health and safety checks were in place. Emergency procedures and contingency plans were in place.

People’s capacity was assumed and staff acted in line with the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. Best interest decision-making followed best practice guidance.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 29 August 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions is the service safe, effective, caring, responsive and well-led to at least good. We found progress had been made and the provider was now meeting these regulations.

However, we also found the provider had breached a further regulation relating to safe care and treatment. Care plans were out of date and no longer reflected people’s needs. In some cases, the required care plans were not in place. This meant staff did not have access to the guidance they needed to ensure people received care that met their needs and kept them safe.

You can see what action we have asked the provider to take at the back of the full version of this report.

Care plans were often not personalised or written in a dignified manner. Care plan evaluations lacked meaningful information and were repetitive. We have made a recommendation about this.

Ashfield Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Ashfield Court accommodates up to 46 people across two separate units, each of which have separate adapted facilities. At the time of our inspection there were 46 people living at the home some of whom were living with dementia.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’ People, relatives and staff gave us good feedback about the registered manager and their management of the home.

The provider’s systems for monitoring the quality of care plans and other care records had not been effective in identifying and dealing with the issues we found. Records confirming the care people had received from staff were not completed accurately. This included records where people required regular positional changes to protect their skin and to monitor their food and fluid intake.

People and relatives gave us positive feedback about the care provided and the kindness of the staff team. Throughout our visits we observed caring interactions between people and staff.

People, relatives and staff told us the service was safe. Staff had a good understanding of safeguarding and the provider’s whistle blowing procedure. Staff said they had no concerns about people’s safety but knew how to raise concerns if needed.

There were enough staff on duty to assist people in a timely way. Staff confirmed told us staffing levels were sufficient and there was a visible staff presence around the home when we visited. The provider had effective recruitment checks to ensure only suitable staff worked at the home, such as Disclosure and Barring Service (DBS) checks and requesting references.

As with our last inspection medicines were managed safely. Accurate records were kept confirming which medicines people had received.

Health and safety checks were up to date. We noted action had been taken to address recommendations made following the most recent fire risk assessment. Procedures were in place to ensure people were kept safe in an emergency.

People’s needs had been assessed both before and after admission to identify their care needs.

Staff told us they were well supported and received the training they needed. Supervisions, appraisals and training were up to date.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People received the support they needed to ensure they had enough to eat and drink. People were supported to access health care services when required.

People and relatives gave us positive feedback but knew how to raise concerns if needed. Previous complaints had been fully investigated in line with the provider’s procedures.

People, relatives and staff described the home as having a warm and friendly atmosphere. There were opportunities for people and staff to give feedback about the home, through attending meetings or filling in questionnaires.

We last carried out a comprehensive inspection of this service in November 2015 where we found the provider was not meeting the regulations relating to safe care and treatment, good governance and staffing. In addition, the provider had not sent us notifications which they are legally required to do as part of their registration. We undertook a focused inspection on 14 June 2016 and found that improvements had been made and they were now meeting legal requirements. We did not change the home’s overall rating at the focused inspection because to do so requires consistent good practice over time.

Ashfield Court provides residential care for up to 46 people, some of whom are living with dementia. Accommodation was spread over two floors. People who were living with dementia lived on first floor. At the time of our inspection there were 44 people living at the service.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager was currently overseeing the management of one of the provider’s nearby nursing homes. He explained that there was the possibility of him becoming manager at this nursing home. As a result, an ‘interim manager’ had been appointed who the registered manager explained would eventually take over his role as manager at Ashfield Court and would register with CQC. She had worked at the service for a number of years. We were supported by both the registered manager and interim manager on both days of the inspection.

On the first day of our inspection, we spoke with people, relatives and day staff who were positive about the home. Following our first visit, we spoke with night staff so we could ascertain how care and support was delivered at night. Certain night staff said that day staff expected them to get most people with a dementia related condition up and dressed in the morning. As a result of this information we carried out another visit to the home at 7.30am.

On the second day of the inspection, we found that most people who lived in the unit for people with a dementia related condition were up and dressed by 7.30am. We spoke with staff who told us they had woken some people at 5am to get them up and dressed.

There were safeguarding and whistleblowing procedures in place. Day staff told us that they had no safeguarding concerns. Certain night staff however, raised several safeguarding allegations. Some night staff told us that they had raised concerns in the past about specific staff and care practices; however no action had been taken. Other staff told us that they had not felt able to raise specific concerns. We passed their concerns to the local authority’s safeguarding team, the registered manager and members of the provider’s senior management team to investigate.

Checks and tests had been carried out to ensure that the premises were safe. An electronic medicines system was used to manage medicines. We found there was a safe and effective system in place for the receipt, storage, administration and disposal of medicines.

Recruitment checks were carried out to ensure that staff were suitable to work with vulnerable people. We checked staff rotas and noted that staffing levels were not always maintained at the numbers advised by the manager. He told us that due to last minute sickness, it was not always possible to get staffing cover. He said they were over recruiting to help ensure they could cover all shifts at the home. We have made a recommendation about this.

Records demonstrated that most staff had completed training in safe working practices and to meet the specific needs of people who lived at the home. There were some gaps in training provision which the interim manager told us she was addressing. Most of the night staff told us that they did not always feel supported in their job role. We found that an effective system to develop, monitor and review staff practices and behaviours was not fully in place to ensure staff were supported to deliver care which met people’s needs.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’ it also ensures unlawful restrictions are not placed on people in care homes and hospitals. Appropriate applications for DoLS had been made by the registered manager. There was evidence that some mental capacity assessments and best interests decisions had been undertaken. However, these were generic and not specific.

People's nutritional needs were met and they were supported to access healthcare services when required.

We observed positive interactions between staff and people who lived at the service on both days of our inspection. Staff told us that they promoted people’s privacy and dignity. However, the practice of assisting some people up early did not promote dignity or person centred care.

People and relatives told us that they were involved in people’s care. This was not always evidenced in the records we viewed.

People and relatives told us that activities provision had improved since the new activities coordinator had started. We had concerns however, about one person’s social inclusion and wellbeing.

There was a complaints procedure in place. None of the people or relatives with whom we spoke raised any concerns.

Audits and checks were carried out to monitor all aspects of the service. We found however, that these audits and checks had not highlighted the issues which had been identified during this inspection such as the culture and morale on night shift and concerns with certain staff practices and behaviours. We also identified shortfalls with certain aspects of record keeping.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to person centred care, safeguarding people from abuse and improper treatment and good governance. You can see what action we told the provider to take at the back of the full version of the report.

Following our inspection in November 2015, the provider sent us an action plan to show us how they would address our concerns and that they would be addressed fully by the 30 April 2016.

At the inspection in November 2015 the provider had also not sent us notifications which they are legally required to do as part of their registration. We dealt with this matter by issuing a fixed penalty notice to both the provider and the registered manager which they accepted and paid.

We undertook this focused inspection on 14 June 2016 to check that the provider had followed their plan and to confirm they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ashfield Court on our website at www.cqc.org.uk

We could not improve the rating for safe or well led from requires improvement because to do so requires consistent good practice over time. We will check these again during our next planned comprehensive inspection.

Ashfield Court provides residential care for up to 46 people, some of whom are living with dementia. At the time of our inspection there were 43 people living at the service including one person who had just been taken into hospital.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that staff levels overnight and daytime shifts were adequate and the provider had increased the number of staff on duty to safely provide care to the people they supported. Staff we spoke with said that they could manage workloads much better now.

The people we spoke with felt safe living at the home and the relatives we spoke with confirmed their views.

Accidents were recorded, monitored and analysed by the registered manager who was fully aware of all accidents that had occurred within the service.

Staff at the service followed safe management of medicines best practice. ‘As required’ medicines were now detailed fully and medicines risk assessments were in place were required. Training in medicines management had been completed and staff had undertaken competency checks to ensure they followed best practice.

We saw very little in the way of activities taking place on the dementia unit and the registered manager said they would look into this. We will follow this up at our next full rated inspection.

We found that there was now a robust range of quality assurance checks in place which were completed by the registered manager, staff and representatives of the provider. These covered areas in connection with health and safety, medicines, care planning, and infection control. The registered manager also had in place a process for monitoring that notifications to the Commission had been sent.

People’s care records and other documents related to their care were now stored in secure locked cabinets, with keys held separately and monitored by administration staff.

We considered all the evidence we had gathered under the regulations we inspected. We used the information to answer the five questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

This is a summary of what we have found.

Is the service safe?

The provider had effective systems in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others. We saw risk assessments had been completed for people who were assessed as being at risk of falls.

We saw people were safe and protected from abuse. Staff demonstrated to us an understanding of the types of possible abuse and how they should be reported. All staff had received training in the safeguarding of vulnerable adults and whistleblowing.

We spoke to people who used the service and asked them if they felt safe there. Comments included, "I have never had any problems. No one comes into my room without my permission" and "I have never had anything taken. It is perfectly safe here." People told us they new how to report any incidents. One person said, "I know how to complain. I would just speak to the manager."

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We saw policies and procedures were in place and the manager and deputy manager had received training in the Mental Capacity Act 2005 (MCA) and DoLS.

Is the service effective?

We saw staff were supported in their role and received the required training. Staff received regular supervision and were supported to develop professionally.

We spoke to staff about the support they received and the training available. Comments included, 'I am supported in my job by the manager' and 'The training is good and there is plenty of it.' This meant staff had the opportunity to discuss their concerns with the provider.

Is the service caring?

People were supported and their care was planned and delivered in line with their care plans. We spoke to people who used the service and asked them about the quality of care they received. Comments included, "I am involved in my care plan. I read it and the girls (staff) are lovely to me" and "I am well looked after. I get a bath when I want and the food is very nice." A visiting relative said, " X is very happy at Ashfield. She is well looked after."

People's preferences, interests and needs were recorded in people's care records. Staff were able to give examples of these when we spoke to them and displayed a good knowledge of the people living at the home and what their needs were.

Is the service responsive?

There was an effective system in place to record and monitor complaints. Complaints were taken seriously and responded to appropriately.

We saw evidence that care staff identified changes in people's needs and acted to make sure they received the care they needed. For example, there was evidence that where one person's health had declined an immediate referral was made to the correct medical professional for advice and support.

Is the service well led?

We saw the manager at the service was registered with the Commission in line with the requirements of the registration of this service and location.

The service had a quality assurance system in place that included the use of surveys from people who used the service, to obtain their opinion.

Overall, we found that medicines were handled safely.

Systems were in place to ensure appropriate staff were recruited to care for people who used the service. There were sufficient staff on duty to care for the people who used the service and they were well trained and supported to carry out their roles.

The provider had taken reasonable steps to identify possible abuse and prevent it from happening.

There were effective systems in place to assess and monitor the quality of service that people received.

People and relatives told us that consent was gained before care was carried out. One person said, 'They always ask me, they never force me to do anything.'

People and relatives were complimentary about the service and the care and support provided. One person told us, 'They look after us great here. There are things going on all the time.' We considered that people experienced care, treatment and support that met their needs.

People told us that they liked a bath or a shower. However, we noted that the home did not have any separate shower units. There were two bathrooms on the ground floor and three bathrooms on the first floor, but only two baths were fitted with the hoisting equipment which was needed to assist people in and out of the water. We concluded that bathing equipment was not available in sufficient quantities in order to meet people's needs, ensure their safety and promote their independence and comfort.

We found that people were cared for by staff who were supported to deliver care safely and to an appropriate standard.

People and relatives said they felt able to raise any concerns to management and make comments about the service. Records confirmed that people were made aware of the complaints system.